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COVID-19 pandemic-related shifts in healthcare utilization, in combination with trends in non-COVID-19 disease transmission and non-pharmaceutical intervention use, had clear impacts on rates of hospitalization for infectious and chronic diseases. Using a U.S. national healthcare billing database, we estimated the monthly incidence rate ratio of hospitalizations between March 2020 and June 2021 according to 19 ICD-10 diagnostic chapters and 189 subchapters. The majority of primary diagnoses for hospitalization showed an immediate decline in incidence during March 2020. Hospitalizations for reproductive neoplasms, hypertension, and diabetes returned to pre-pandemic levels during late 2020 and early 2021, while others, like those for infectious respiratory disease, did not return to pre-pandemic levels during this period. Our assessment of subchapter-level primary hospitalization codes offers insight into trends among less frequent causes of hospitalization during the COVID-19 pandemic in the U.S., (© 2022. The Author(s).)

Objectif: Évaluer l'effet du clampage retardé du cordon et de la traite du cordon ombilical sur les risques de mortalité et de morbidité maternelles et néonatales en contexte de grossesses monofœtale ou gémellaire., Population Cible: Femmes enceintes dont la grossesse monofœtale ou gémellaire est à terme ou avant terme., Bénéfices Risques Et Coûts: Chez les prématurés de grossesse monofœtale, le clampage retardé de 60 à 120 secondes idéalement, mais d'au moins 30 secondes, réduit le risque de mortalité et de morbidité. Chez les jumeaux prématurés, le clampage retardé est associé à certains bénéfices. Chez les nourrissons de grossesse monofœtale à terme, le clampage retardé de 60 secondes améliore les paramètres hématologiques. Chez les grands prématurés, la traite du cordon ombilical augmente le risque d'hémorragie intraventriculaire., Données Probantes: Une recherche a été effectuée au moyen des bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2020, à partir de termes MeSH et de mot-clés liés au clampage retardé du cordon et à la traite du cordon ombilical. Le présent document est un résumé des données probantes et non pas une revue méthodologique., Méthodes De Validation: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles])., (© Cet article a été publié dans son intégralité dans le Journal d’obstétrique et gynécologie du Canada. Vol. 44. McDonald, SD, Narvey, M, Ehman, William, Jain, Venu, Cassell, Krista.Directive clinique no 424 : Prise en charge du cordon ombilical chez le nourrisson prématuré ou à terme, P313-22.E1. Copyright La Société des obstétriciens et gynécologues du Canada (2022).)

Objective: To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity., Target Population: Women who are pregnant with preterm or term singletons or twins., Benefits Harms and Costs: In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage., Evidence: Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. This document represents an abstraction of the evidence rather than a methodological review., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations)., (© This article was published in full text in the Journal of Obstetrics and Gynaecology Canada. Vol 44. McDonald, SD, Narvey, M, Ehman, William, Jain, Venu, Cassell, Krista. Guideline No. 424: Umbilical Cord Management in Preterm and Term Infants, P313-322.E1. Copyright The Society of Obstetricians and Gynaecologists of Canada (2022).)

Importance: There are limited high-quality, population-level data about the effect of SARS-CoV-2 infection on pregnancy using contemporaneous comparator cohorts., Objectives: To describe maternal and perinatal outcomes associated with SARS-CoV-2 infection in pregnancy and to assess variables associated with severe disease in the pregnant population., Design, Setting, and Participants: CANCOVID-Preg is an observational surveillance program for SARS-CoV-2-affected pregnancies in Canada. This analysis presents exploratory, population-level data from 6 Canadian provinces for the period of March 1, 2020, to October 31, 2021. A total of 6012 pregnant persons with a positive SARS-CoV-2 polymerase chain reaction test result at any time in pregnancy (primarily due to symptomatic presentation) were included and compared with 2 contemporaneous groups including age-matched female individuals with SARS-CoV-2 and unaffected pregnant persons from the pandemic time period., Exposure: SARS-CoV-2 infection during pregnancy. Incident infections in pregnancy were reported to CANCOVID-Preg by participating provinces/territories., Main Outcomes and Measures: Maternal and perinatal outcomes associated with SARS-CoV-2 infection as well as risk factors for severe disease (ie, disease requiring hospitalization, admission to an intensive care unit/critical care unit, and/or oxygen therapy)., Results: Among 6012 pregnant individuals with SARS-CoV-2 in Canada (median age, 31 [IQR, 28-35] years), the greatest proportion of cases were diagnosed at 28 to 37 weeks' gestation (35.7%). Non-White individuals were disproportionately represented. Being pregnant was associated with a significantly increased risk of SARS-CoV-2-related hospitalization compared with SARS-CoV-2 cases among all women aged 20 to 49 years in the general population of Canada (7.75% vs 2.93%; relative risk, 2.65 [95% CI, 2.41-2.88]) as well as an increased risk of intensive care unit/critical care unit admission (2.01% vs 0.37%; relative risk, 5.46 [95% CI, 4.50-6.53]). Increasing age, preexisting hypertension, and greater gestational age at diagnosis were significantly associated with worse maternal outcomes. The risk of preterm birth was significantly elevated among SARS-CoV-2-affected pregnancies (11.05% vs 6.76%; relative risk, 1.63 [95% CI, 1.52-1.76]), even in cases of milder disease not requiring hospitalization, compared with unaffected pregnancies during the same time period., Conclusions and Relevance: In this exploratory surveillance study conducted in Canada from March 2020 to October 2021, SARS-CoV-2 infection during pregnancy was significantly associated with increased risk of adverse maternal outcomes and preterm birth.

Objective: To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity., Target Population: People who are pregnant with preterm or term singletons or twins., Benefits, Harms, and Costs: In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage., Evidence: Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. This document represents an abstraction of the evidence rather than a methodological review., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations)., Intended Users: Maternity and newborn care providers., (Copyright © 2022 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Denmark has one of the highest Legionnaires' disease notification rates within Europe, averaging 4.7 cases per 100,000 population annually (2017 to 2020). The relatively high incidence of disease is not uniform across the country, and approximately 70% of all domestically acquired cases in Denmark are caused by Legionella pneumophila (LP) strains that are considered less virulent. The aim of this study was to investigate if colonization rates, levels of colonization, and/or types of LP present in hot water systems were associated with geographic differences in Legionnaires' disease incidence. Domestic water systems from four cities in Denmark were analyzed via culture and qPCR. Serogrouping and sequence typing was performed on randomly selected isolates. Single nucleotide polymorphism was used to identify clonal relationship among isolates from the four cities. The results revealed a high LP colonization rate from 68% to 87.5% among systems, composed primarily of non-serogroup 1. LP serogroup 1 reacting with the monoclonal antibody (MAb) 3/1 was not identified in any of the systems tested, while MAb 3/1 negative serogroup 1 strains were isolated from 10 systems (9.6%). We hypothesize that a combination of factors influences the incidence rate of LD in each city, including sequence type and serogroup distribution, colonization rate, concentration of Legionella in Pre-flush and Flush samples, and potentially building characteristics such as water temperature measured at the point of use.

Health studies report associations between metrics of residential proximity to unconventional oil and gas (UOG) development and adverse health endpoints. We investigated whether exposure through household groundwater is captured by existing metrics and a newly developed metric incorporating groundwater flow paths. We compared metrics with detection frequencies/concentrations of 64 organic and inorganic UOG-related chemicals/groups in residential groundwater from 255 homes (Pennsylvania n = 94 and Ohio n = 161). Twenty-seven chemicals were detected in ≥20% of water samples at concentrations generally below U.S. Environmental Protection Agency standards. In Pennsylvania, two organic chemicals/groups had reduced odds of detection with increasing distance to the nearest well: 1,2-dichloroethene and benzene (Odds Ratio [OR]: 0.46, 95% confidence interval [CI]: 0.23-0.93) and m- and p- xylene (OR: 0.28, 95% CI: 0.10-0.80); results were consistent across metrics. In Ohio, the odds of detecting toluene increased with increasing distance to the nearest well (OR: 1.48, 95% CI: 1.12-1.95), also consistent across metrics. Correlations between inorganic chemicals and metrics were limited (all |ρ| ≤ 0.28). Limited associations between metrics and chemicals may indicate that UOG-related water contamination occurs rarely/episodically, more complex metrics may be needed to capture drinking water exposure, and/or spatial metrics in health studies may better reflect exposure to other stressors.

BackgroundLegionnaires' disease (LD) incidence has been increasing in several European countries since 2011. Currently, Denmark is experiencing one of the highest annual incidences of LD despite its relatively cold climate and homogenous population, and the incidence differs notably across the country.AimWe sought to determine whether provincial differences in LD incidence are attributable to the age and sex distribution of the population, and to characterise the risk of LD by province and age group in Denmark.MethodsUsing national routine surveillance data for domestic LD cases collected between 2015 and 2018, we assessed the incidence of disease by province and year. Poisson regression models were fit to understand the risk of LD by year and province, as well as by 5-year age groups.ResultsIncidence of domestic LD increased 48% between 2015 and 2018 across Denmark. Some provinces continuously had a high incidence of disease, even after adjusting for yearly trends and the underlying population distribution. Variations in the proportion of the population aged 65 years and older were not responsible for the increase in disease in our analysis. Finally, incidence of disease increased with each 5-year age group in both men and women.ConclusionsThe relative differences in incidence between Danish provinces could not be explained by the age and sex distribution of the population, indicating that other factors must be responsible for the varying incidence across the country. These results may help inform trends in other countries in Europe also experiencing an unexplained high incidence of LD.

While case reports have documented recurrence of Legionnaires' disease, the frequency of recurrent infections has not been systematically examined at a national level over multiple decades. Between 2000 and 2020 in Denmark, 21 individuals had repeat laboratory-identified Legionella infection, totalling 48 episodes of hospitalisation. The majority of these individuals had underlying comorbidities. In at least 3 of the 21 cases, a different Legionella serogroup was detected during the second episode of infection, which could indicate reinfection from a new source. These results emphasise that Legionella can, and does, reinfect high-risk individuals causing multiple hospitalisations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Over the past decade, the reported incidence of Legionnaires' disease (LD) in the northeastern United States has increased, reaching 1-3 cases per 100,000 population. There is reason to suspect that this is an underestimate of the true burden, since LD cases may be underdiagnosed. In this analysis of pneumonia and influenza (P&I) hospitalizations, we estimated the percentages of cases due to Legionella, influenza, and respiratory syncytial virus (RSV) by age group. We fitted mixed-effects models to estimate attributable percents using weekly time series data on P&I hospitalizations in Connecticut from 2000 to 2014. Model-fitted values were used to calculate estimates of numbers of P&I hospitalizations attributable to Legionella (and influenza and RSV) by age group, season, and year. Our models estimated that 1.9%, 8.8%, and 5.1% of total (all-ages) inpatient P&I hospitalizations could be attributed to Legionella, influenza, and RSV, respectively. Only 10.6% of total predicted LD cases had been clinically diagnosed as LD during the study period. The observed incidence rate of 1.2 cases per 100,000 population was substantially lower than our estimated rate of 11.6 cases per 100,000 population. Our estimates of numbers of P&I hospitalizations attributable to Legionella are comparable to those provided by etiological studies of community-acquired pneumonia and emphasize the potential for underdiagnosis of LD in clinical settings., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectifs: Fournir des directives factuelles qui favorisent l'accouchement vaginal assisté sécuritaire et efficace. RéSULTATS: Conditions préalables, indications, contre-indications, ainsi que les morbidités maternelles et néonatales liées à l'accouchement vaginal assisté. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline pour trouver des articles publiés entre le 1 er  janvier 1985 et le 28 février 2018 en utilisant les termes anglais suivants : assisted vaginal birth, instrumental vaginal birth, operative vaginal delivery, forceps delivery, vacuum delivery, ventouse delivery. La qualité des données probantes indiquées s'appuie sur les critères d'évaluation des données décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs., Validation: La présente directive a été approuvée par le comité de pratique clinique - obstétrique et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada. RECOMMANDATIONS., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: To provide evidence-based guidelines for safe and effective assisted vaginal birth., Outcomes: Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth., Evidence: Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words "assisted vaginal birth," "instrumental vaginal birth," "operative vaginal delivery," "forceps delivery," "vacuum delivery," "ventouse delivery." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care., Validation: These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: There has been a dramatic increase in the incidence of sporadic legionnaires' disease in Connecticut since 1999, but the exact reasons for this are unknown. Therefore, there is a growing need to understand the drivers of legionnaires' disease in the community. In this study, we explored the relationship between the natural environment and the spatial and temporal distribution of legionellosis cases in Connecticut., Methods: We used spatial models and time series methods to evaluate factors associated with the increase and clustering of legionellosis in Connecticut. Stream flow, proximity to rivers, and residence in regional watersheds were explored as novel predictors of disease, while controlling for testing intensity and correlates of urbanization., Results: In Connecticut, legionellosis incidence exhibited a strong pattern of spatial clustering. Proximity to several rivers and residence in the corresponding watersheds were associated with increased incidence of the disease. Elevated rainfall and stream flow rate were associated with increases in incidence 2 weeks later., Conclusions: We identified a novel relationship between the natural aquatic environment and the spatial distribution of sporadic cases of legionellosis. These results suggest that natural environmental reservoirs may have a greater influence on the spatial distribution of sporadic legionellosis cases than previously thought., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Flooding is a major disturbance that impacts aquatic ecosystems and the ecosystem services that they provide. Predicted increases in global flood risk due to land use change and water cycle intensification will likely only increase the frequency and severity of these impacts. Extreme flooding events can cause loss of life and significant destruction to property and infrastructure, effects that are easily recognized and frequently reported in the media. However, flooding also has many other effects on people through freshwater aquatic ecosystem services, which often go unrecognized because they are less evident and can be difficult to evaluate. Here, we identify the effects that small magnitude frequently occurring floods (< 10-year recurrence interval) and extreme floods (> 100-year recurrence interval) have on ten aquatic ecosystem services through a systematic literature review. We focused on ecosystem services considered by the Millennium Ecosystem Assessment including: (1) supporting services (primary production, soil formation), (2) regulating services (water regulation, water quality, disease regulation, climate regulation), (3) provisioning services (drinking water, food supply), and (4) cultural services (aesthetic value, recreation and tourism). The literature search resulted in 117 studies and each of the ten ecosystem services was represented by an average of 12 ± 4 studies. Extreme floods resulted in losses in almost every ecosystem service considered in this study. However, small floods had neutral or positive effects on half of the ecosystem services we considered. For example, small floods led to increases in primary production, water regulation, and recreation and tourism. Decision-making that preserves small floods while reducing the impacts of extreme floods can increase ecosystem service provision and minimize losses.

Objective: To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions., Evidence: Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2011 and 2012 using appropriate controlled vocabulary and key words (female genital cosmetic surgery). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A) 2. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B) 3. Counselling should be a priority for women requesting female genital cosmetic surgery. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process. (III-L) 4. There is little evidence to support any of the female genital cosmetic surgeries in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided (III-L) 5. Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L) 6. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L).